Mental health

A 27-year-old woman was being treated with gastrojejunostomy feeding for severe anorexia nervosa. The position of the gastrojejunostomy tube was checked by fluoroscopy on the day of insertion (Figure, A, arrow). The next day, the patient presented with abdominal pain and “shortening” of the external portion of the tube. Repeat fluoroscopy showed migration of the tube (Figure, B, arrow). Computed tomography showed two segments of jejunojejunal intussusception (Figure, C, arrow and inset, and D, straight arrow) centred around the tube (Figure, D, curved arrow), with an intervening segment of normal jejunum (Figure, D, label J). The patient’s gastrointestinal tract was intact. The intussusceptions were reduced by applying traction on the tube under fluoroscopic guidance, and the patient resumed tube feeding without recurrence.

Uei Pua

The difficulties of knowing when, and to whom, to refer patients with a mental disorder Recognising one’s clinical limitations and the need for them to be augmented by others’ specialised knowledge and experience is a key component of professional reflectiveness and humility. Referring a patient to a specialist should never be experienced as a reflection of inadequacy or as a slight upon the quality of one’s care. It is an opportunity to provide enhanced treatment and to draw collaboratively upon the specialisation and wisdom of a respected colleague.1 It is also an important ethical obligation.2 By contrast, a failure to be conscious of one’s limitations can lead to insensitivity to the repercussions of patients’ symptoms, erroneous diagnoses and treatment, and a failure to attend adequately to risk factors. There are many possible reasons for this, which have been described in some instances as potentially including narcissism, grandiosity or a sense of omniscience,3 or therapeutic nihilism.4 Depending on the clinical outcome, non-referral can result in actions for negligence and disciplinary consequences. Mental illness is, by nature, episodic, with symptoms waxing and waning at different periods of a patient’s life and in response to different triggers and vulnerabilities. This highlights the need for a longitudinal perspective on the course of a mental disorder to identify improvement, deterioration or the existence of cycles of symptoms, all of which can give rise to therapeutic opportunities. Continuing evaluation of the need for pharmacotherapy, psychotherapy or any other modality is important. Matters can be complicated by patients resorting to unorthodox forms of intervention, such as “vitamin therapies”, past-life therapy and counselling from unqualified practitioners, all of which have the potential to exacerbate or briefly camouflage symptoms and warning signs.5 Practitioners’ perspectives of their patients’ mental states are inevitably snapshots taken at times that might not be representative of the course or trajectory of the illness. This is especially so in relation to bipolar disorder. Bipolar II disorder poses particular clinical challenges because of the risk that a practitioner seeing a patient irregularly will fail to identify hypomanic episodes and misdiagnose by reference only to observed or reported depression or anxiety. This risk is graphically illustrated in this issue of the Journal by Parker, in the context of the coronial inquest into the death of Charmaine Dragun.6 It is incumbent upon practitioners to be alert to dangerously labile moods suggestive of bipolar I or II disorder. Where signs of bipolar disorder are identified, there is frequently a need to refer the patient to a psychiatrist to manage and to titrate medication. Such referrals must be informed and suitably selective. Indiscriminate referrals run the risk of using the services of a psychologist or a counsellor in cases where such practitioners may not be the most suitable providers of treatment. This can be a particular issue in the era of mental health care plans, in which there can be pressures on general practitioners, driven by financial considerations, to refer to non-medically qualified practitioners who may not be the best equipped to deal with psychiatric illness. A survey of psychiatrists in the United Kingdom and the United States identified early referral to appropriate specialist care as being one of the “highest priority needs” in the effective management of patients diagnosed with bipolar disorder.7 Such patients are at real and foreseeable danger of lifestyle harm (such as severe embarrassment and financial loss), of taking risks that might endanger their own or others’ safety, and of suicide. These dangers can be avoided by timely referral to specialists with experience in the diagnosis and treatment of patients with bipolar disorders. However, the advantages of suitable and timely referral go beyond the practice of prudent and defensive medicine. Such referral enables focused and intensive provision of treatment for patients who might have limited insight into their illness and the need for treatment, as well as ambivalence about seeking assistance for their symptoms. In the legal context, the scenarios in which failures to refer have most commonly been litigated have been in relation to cancer investigations, when malignant tumours have been misdiagnosed as benign or have not been identified at all,8 and when there has been the potential for, or reality of, a boundary blurring or transgression. An example of the latter is when moves have commenced toward the creation of an unethical romantic or sexual relationship between practitioner and patient, and the doctor has not referred the patient to another practitioner. The principle underlying the obligation to refer in both scenarios is the same — that another practitioner is better positioned to advance the patient’s interests and that non-referral will disadvantage the wellbeing of the patient, breaching the obligation to exercise reasonable care and skill in the provision of professional advice and treatment.9,10 However, the referral must be clinically appropriate. In a New South Wales case, this was illustrated by a GP being found civilly liable to his patient for referring him to a chiropractor from whom he received treatment that was foreseeably clinically contraindicated because the patient had degenerative cervical changes and neurological symptoms from a disc injury.11 The same issue arises in respect of patients who might have bipolar disorder. This is not to say that a suitably experienced GP might not be able to treat such patients adequately; rather, that it can be negligent not to take active steps to enable patients to avail themselves of the specialist care that might be able to manage their illness most intensively at the time. Such a referral is also a significant protection for the practitioner, should allegations of insufficient or inadequately informed care be made later by the patient or the patient’s dependants.

Ian R Freckelton SC, LLB, PhD · George Mendelson MD, FRANZCP, FFPMANZCA

A coronial inquest into the suicide of television newsreader Charmaine Dragun identified that a likely contributory factor to her death was the failure of many health practitioners to diagnose a bipolar II disorder and to provide more specific treatment for her condition. Lack of awareness about bipolar II disorder among practitioners and the public, as well as screening and detection problems, may have contributed to the failure to diagnose this disorder over the course of a decade. Detection and management of bipolar II disorder generally differs from that for a unipolar disorder, in that mood stabilisers rather than antidepressants are more often a priority. The diagnosis therefore has distinctive implications for management and course of the illness. The Coroner recommended “increased awareness by health professionals of the need to exclude a bipolar disorder in all patients presenting with signs and symptoms of depression” and highlighted the need for “readily available” screening tools.

Gordon B Parker AO, MD, PhD, FRANZCP

To the Editor: Amid debate about growth in the number of Disability Support Pension (DSP) recipients and the increasing percentage of recipients with mental disorders,1,2 the recent federal Budget announced further welfare reforms and significant investment in mental health services.3 There are, however, limitations in the data informing the current discussion. Administrative data are restricted to coding the primary disability of DSP recipients, and do not assess comorbidity. Further, data on the health of recipients receiving other welfare payments are lacking, precluding thorough understanding of the context of the growth in the DSP population. We recently published an analysis of the 2007 Australian Bureau of Statistics National Survey of Mental Health and Wellbeing, in which we estimated the prevalence of common mental disorders in different categories of working-age welfare recipients.4 The main results showed that just over one-third (34%) of income-support recipients had a 12-month affective, anxiety and/or substance use disorder, compared with 20% of non-recipients; that, despite a decade of reform of the welfare and mental health systems and improved economic circumstances, there had been little change in the overall prevalence of mental disorders among welfare recipients since 1997 (Box, A);5 and that most income-support recipients with mental disorders received payments other than DSP. We compared data from the 1997 and 2007 surveys, focusing on welfare recipients with a mental disorder (12-month common mental disorder assessed by the World Mental Health Composite International Diagnostic Interview). Of the 10 641 and 8841 survey respondents in 1997 and 2007, 667 and 362, respectively, were identified as working-age welfare recipients with a mental disorder.5 We estimated that 31% of income-support recipients with mental disorders were DSP recipients in 1997, but in 2007 this had increased to 45% (Box, B). The increased concentration of recipients with mental disorders receiving the DSP was significant in logistic regression models controlling for age and sex (odds ratio, 1.72; 95% CI, 1.05–2.83).5 The increased profile of mental disorders among DSP recipients may reflect shifts between payments within the welfare recipient population. Although this could be due to financial incentives to receive DSP rather than lower-paying allowances (eg, Newstart Allowance), the results may reflect that some income-support recipients with a mental disorder are unable to comply with the new activity or work requirements introduced by recent policy changes.6 Careful consideration is needed of the potential adverse unintended consequences of welfare reforms for the large number of income-support recipients with mental disorders. Changes that promote DSP as the most appropriate option for people with mental disorders risk entrenching their alienation from the workforce. Mental disorders and welfare recipients (with 95% CIs), 1997 and 20075 DSP = Disability Support Pension.

Peter Butterworth · Philip M Burgess · Harvey Whiteford

To the Editor: Katelaris recently asserted: In our society the response to medical error is typically legal, rather than investigative and remedial. This should be deplored by both the profession and the public.1 This polarised orientation seems more political than objective. It acknowledges neither the reticence of medical professionals regarding investigative reviews, nor the costs to patients’ families. Katelaris notes that defensive approaches encourage the concealment of errors. I have long advocated clinical reviews of critical incidents. Having personally set up Queensland Health’s original Suicide Register, I released statewide patient suicide data to health services. Reactions from service providers were decidedly underwhelming, despite the gravity of the outcomes. Katelaris did not explain how clinical reviews can address the problem of income replacement or other major costs associated with catastrophic outcomes for patients’ families. In the 1990s, I reviewed all Australian litigation for failure to prevent suicidal behaviour in care, through a survey of insurers and defendant solicitors.2 Of the 13 non-fatal cases identified, paraplegia occurred in seven patients, with other serious injuries in the remaining six. These were not trivial complaints. I also reviewed what might be learnt from the international literature3 and made known my availability to assist with clinical reviews of patient suicides. Despite having been an expert witness at the Royal Commission into Aboriginal Deaths in Custody and a Royal Australian Navy inquiry into the loss of a sailor who disappeared overboard in 2002, among others, no medical services have sought my assistance over more than 20 years! I understand, from personal experience, how distressing trivial and vexatious complaints against doctors are. I have even received a complaint for providing a report to a plaintiff’s solicitor, in relation to failure to prevent suicidal behaviour, in which I asserted that reasonable care had been provided. I now run a personal-injury psychiatric practice, with alleged medical negligence featuring in about 3% of cases. Mostly I am called by the plaintiff’s side, often following devastating surgical outcomes. Referral bias operates, in that negative surgical outcomes with psychiatric consequences are likely to have been more serious than those without. The outcomes have often been both emotionally and financially devastating to those affected. I long to see a medically mature culture develop with respect to clinical reviews of critical incidents, but my experience suggests we still have a way to go. But even when or if such a medical utopia is achieved, how will the financial disadvantages to patients’ families be overcome?

Christopher H Cantor

Psychiatrist Diana McKay explains why she chose the public hospital system PUBLIC: There’s nothing like surprising your medical colleagues. Almost a year ago, I announced to some colleagues that, after 6 or so years primarily in private practice as a psychiatrist, I was shutting up shop and returning to work as a staff specialist in a busy public hospital. There was a notable pause before the congratulations ensued. Friends and private patients asked me why was I going to work in the public sector? I gave a mixture of responses, such as wanting to improve “the system”, becoming more involved in teaching, and a desire to use my skills with those unable to pay privately for them. Personally, with my children getting older, I felt I had more energy — and hopefully more wisdom and patience — to invest in an often demanding health system. I’m now not quite at my first anniversary of being fully back in the public sector. Professionally, it has been both challenging and rewarding. I’m lucky enough to work in a teaching hospital small enough to enable personal relationships to be the key currency of professional connections. My immediate colleagues are a small but cohesive group, who meet regularly to discuss service and clinical difficulties (there are always several to raise) in a thoughtful manner. Our management team is happy to listen to new ideas, although (it goes without saying) innovation must always involve innovation with the budget as well. Relationships between professions are respectful, and the “us” and “them” dynamics that I have experienced elsewhere seem little apparent. The passion and commitment of staff are evident throughout the hospital. The clinical variety is considerable, with the need for further study and reflection much in evidence. I am often reminded of Hippocrates’ aphorism “ars longa, vita brevis” (the craft is long, life is short) as I search online for the latest information on treatments and complications to discuss with my patients. The work can be difficult, but it is a privilege to work with people often at their most vulnerable — frequently people I would not have seen in private practice because they could not have paid for my services there. A sense of contributing to social justice has been one reward of my return to the public sector. It is not, however, all a land of milk and honey. Being on-call is tiring, and can be stressful at times when there is demand for inpatient services but access block preventing patients from being admitted. Somehow, the hospital and I have found a path through these occasions, again, with the goodwill of many staff who work together to ensure a bed is found for someone who needs it. Other challenges include the stark realities of the gaps in our system generally, with care provided to those with intellectual disability being one example. It’s hard not to feel guilty when a person is sent away because their needs are not part of our purview, particularly when I’m aware of what limited options are available anywhere. Although it feels a bit infra dig to mention remuneration, it is true that a staff specialist earns less than someone in the same specialty in private practice. This difference is less stark in my non-procedural specialty than in others, but must be acknowledged. There are the benefits of being an employee: paid holidays, study leave, a training allowance (with some irritations attached — just ask me about the interpretation that a computer does not constitute study “equipment”) and no late-night chat sessions with my accountant discussing the benefits of cash versus accrual accounting. The money — even if it is less than I could earn elsewhere — arrives with pleasing regularity in my bank account, with the needful done. The inexplicable delays in organising some basic things like email access has provided ample opportunity for me to revise the serenity prayer (http://en.wikipedia.org/wiki/Serenity_Prayer). I suggest all staff specialists keep a copy near their elderly computers to assist them in times of bureaucratic or information technology crisis. Another challenge can be the freedom to join in public debate, even in a forum such as this. The New South Wales Health code of conduct reminds me of many very pertinent and sensible things, but also that I must not use my job title when engaging in sociopolitical debate; hence my vanilla listing in this article. I have watched a few colleagues thoughtfully ignore this stipulation and speak out on issues they feel are in the public interest, and I wonder how I would manage if (or when) I were in the same situation. I have spoken about my own outcomes in this debate, but little about the outcomes of those who matter most in any health care debate — the patients. It seems to me that the jury is out on whether the public or private sector provides the best outcomes, with lack of access to data limiting the confidence with which conclusions can be drawn.1 From my personal viewpoint, it matters less to me how health care is delivered than how it can be accessed. At present the rather fragmented Australian health care system allows only some people access to private health care, and this seems inequitable. If we want private and public good for ourselves and our patients, we need to consider how the principle of universal access can more effectively integrate both sectors. This would be truly innovative.

Diana R McKay MB BS, BSc(Med), FRANZCP

To the Editor: The supplement of the Journal published on 16 August 2010 — “Bipolar disorder: new understandings, emerging treatments”1 — illustrates a number of features of the current implementation of the Journal’s supplement policy that are problematic. While it is clearly stated that the supplement “was supported by an unconditional grant from AstraZeneca Neuroscience”, the amount of sponsorship, to whom it was paid, and how it was used were not disclosed. Such information is particularly pertinent as evidence suggests that the pharmaceutical industry has financial motivation to see a widening of the diagnostic boundaries of bipolar disorder and a rebadging of atypical antipsychotics as “mood stabilisers”.2 The provenance of the articles is not revealed — it is not clear whether the articles were solicited, part of a symposium, or from some other source. Bipolar disorder is a controversial area in psychiatry,3 yet despite much useful information in the articles in the supplement, discussion of this controversy is a minor feature and no significant critical appraisal is offered. To give a more balanced view to readers, it would have been desirable to have included articles that highlight the controversy regarding bipolar II and bipolar spectrum diagnoses and discuss the ways in which personality disorders arising from developmental trauma and attachment problems can present with mood and behavioural disturbances that can be confused with bipolar disorder.

Jon N Jureidini · Peter I Parry · Catherine M Houen · Malcolm W Battersby

In reply: Jureidini and colleagues raise legitimate issues pertinent to our Medical Journal of Australia supplement on bipolar disorders, and we are pleased to respond. First, the extent of sponsorship from AstraZeneca was for publication only. One of us (D J C) discussed the idea of the supplement with the Editor of the Journal, and AstraZeneca expressed interest in supporting the project. Neither the Journal editors nor any of the supplement authors were involved in the sponsorship negotiations between AstraZeneca and the publisher of the Journal, and neither received any financial or other assistance or reimbursement from AstraZeneca. Second, as Coordinating Editors of the supplement, we determined the content of the supplement without any input from AstraZeneca, and we directly solicited articles from leading experts of our choice in appropriate fields. All articles were subject to the usual review process accorded all publications in the Journal. Regarding the general issue of the boundaries of the bipolar concept, we are very much aware of the ongoing debate. This is a pervasive issue for a discipline devoid of biological markers that can be used to define a plane of cleavage. Indeed, we highlighted this in the second paragraph of our editorial1 as an “immediate area of controversy”. We also solicited the article by Tiller and Schweitzer specifically to address the diagnostic problems in the area of mood instability; in that article, there is specific mention of both the bipolar spectrum and mood instability in the so-called personality disorders.2 With respect, Jureidini and colleagues fall into a common trap by considering that the use of some atypical antipsychotics in bipolar disorder is a rebadging exercise. This is silliness. One could equally argue that sodium valproate, carbamazepine and lamotrigine are not legitimate mood stabilisers but, rather, rebadged anticonvulsants. Tricyclic antidepressants started life as antihistamines. What matters to us as clinicians and researchers is that people with bipolar disorder are offered the best possible care, irrespective of labels. We are also very much aware of the undeniable burden associated with mood instability and hope that the supplement we helped produce will assist general practitioners, in particular, to deliver better care to patients so afflicted.

David J Castle · Michael Berk · Barbara M Hocking

Objective: To examine age and sex differences in the leading causes of prevalent disability in young Australians.Design, setting and participants: We analysed data from the 2003 Australian Burden of Disease and Injury Study, which estimated the prevalent disability burden attributable to 170 diseases and injuries, for younger adolescents (10–14 years), older adolescents (15–19 years) and young adults (20–24 years).Main outcome measures: The broad categories of disease and injury that are the main contributors to prevalent disability and the 10 leading disease and injury causes of prevalent disability, according to sex and age group.Results: Total prevalent disability rates are lowest in younger adolescents and highest in young adults. Mental disorders are the largest “contributor” to disability in young Australians, and anxiety and depressive disorders are the leading single cause. In young males, autism and attention deficit hyperactivity disorder cause similar levels of disability as do anxiety and depression. In young females, eating disorders are the second leading cause of mental disorder disability. Alcohol use disorders and schizophrenia make important contributions to disability in young adult males. Asthma is the most prominent cause of physical disability in all three age groups.Conclusions: There are substantial changes in both the pattern and level of disability burden across the three age groups that we studied. The increase in total prevalent disability that occurs from early adolescence to young adulthood should focus attention on the delivery of accessible and youth friendly health care as well as the effectiveness of transitions from child health services to adult health services.

Rebecca R S Mathews MPH · Wayne D Hall PhD · Theo Vos PhD · George C Patton MD, FRANZCP · Louisa Degenhardt PhD

To the Editor: Two studies in nursing homes in Sydney, New South Wales, in the 1990s1,2 showed inappropriately high use of psychotropic medications. A similar study was conducted in 2003.3 Over time, revision of management guidelines, warnings about potentially lethal side effects, and introduction of new drugs have contributed to changes in the pattern of use of psychotropic medications in aged care facilities. Following the same procedure as the earlier studies, in 2009, we examined medication use in nursing homes in half the catchment area of Sydney South West Area Health Service (SSWAHS). We obtained details of drugs prescribed for residents from medication record cards in 44 of the area’s 48 nursing homes and checked whether medications had been given as prescribed. If given regularly on at least 25 of the previous 28 days, use was recorded as regular. We noted whether medication prescribed “as required” had been taken. The SSWAHS ethics review committee approved the study. Medication cards of all 2465 residents (895 men, 1570 women; mean age, 78.7 and 84.2 years, respectively) were reviewed. The mean number of all medications charted per resident was 8.7. Data obtained from all four surveys on patients taking psychotropic medication regularly are shown in the Box. The catchment area expanded between the 1998 and 2003 surveys. However, half the nursing homes open in 1993 closed before 2009. Use of antipsychotic agents fell between 1993 and 1998. By 2003 there had been a change from conventional antipsychotics to a two-to-one preference for atypical antipsychotic medication. Since 2003, regular use of antipsychotic medication has increased by about 19%, although at a lower mean dosage than previously. The rise is mainly attributable to increased prescription of risperidone and needs continuing review to monitor for morbidity. The proportion of residents taking antipsychotic medication only as required has remained almost the same in each survey (range, 1.2%–1.4%). Regular use of anxiolytic and hypnotic medication has decreased, and of antidepressants has increased, since the 1990s. Only 3.5% of residents were regularly taking a tricyclic antidepressant in 2009. The proportions of residents prescribed anxiolytic or hypnotic medication only as required have also fallen (to 3.8% and 2.3%, respectively, in the 28 days preceding our audit). Our findings cannot be generalised. Recent evidence from Tasmania4 showed that 42% of residents were taking benzodiazepines regularly. Nevertheless, changes in medication use should provoke discussion. Number (%*) of Sydney nursing home residents taking psychotropic medication regularly Medication 19931 (n = 2414) 19982 (n = 1975) 20033 (n = 3093) 2009 (n = 2465) Any psychotropic† 1422 (58.9%) 957 (48.5%) 1461 (47.2%) 1170 (47.5%) Antipsychotics‡ 662 (27.4%) 447 (22.6%) 730 (23.6%) 690 (28.0%) Conventional‡ 662 (27.4%) 401 (20.3%) 251 (8.1%) 182 (7.4%) Haloperidol 190 (7.9%) 159 (8.1%) 167 (5.4%) 121 (4.9%) Thioridazine 354 (14.7%) 193 (9.8%) 17 (0.5%) — Chlorpromazine 53 (2.2%) 24 (1.2%) 25 (0.8%) 20 (0.8%) Trifluoperazine 57 (2.4%) 30 (1.5%) 16 (0.5%) 8 (0.3%) Pericyazine 15 (0.6%) 3 (0.2%) 10 (0.3%) 13 (0.5%) Fluphenazine 44 (1.8%) 23 (1.2%) 10 (0.3%) 11 (0.4%) Flupenthixol — 2 (0.1%) 9 (0.3%) 7 (0.3%) Zuclopenthixol — — — 9 (0.4%) Atypical‡ 48 (2.4%) 506 (16.4%) 537 (21.8%) Olanzapine — 8 (0.4%) 225 (7.3%) 180 (7.3%) Risperidone — 40 (2.0%) 219 (7.1%) 286 (11.6%) Quetiapine — — 18 (0.6%) 63 (2.6%) Amisulpride — — 4 (0.1%) 7 (0.3%) Clozapine — — 3 (0.1%) 7 (0.3%) Aripiprazole — — — 4 (0.2%) Hypnotics‡ 641 (26.6%) 335 (17.0%) 350 (11.3%) 274 (11.1%) Temazepam 530 (22.0%) 313 (15.8%) 307 (9.9%) 255 (10.3%) Nitrazepam 105 (4.3%) 17 (0.9%) 35 (1.1%) 17 (0.7%) Anxiolytics‡ 207 (8.6%) 123 (6.2%) 127 (4.1%) 117 (4.7%) Diazepam 113 (4.7%) 77 (3.9%) 92 (3.0%) 71 (2.9%) Oxazepam 72 (3.0%) 40 (2.0%) 32 (1.0%) 26 (1.1%) Antidepressants‡ 377 (15.6%) 316 (16.0%) 635 (20.5%) 630 (25.6%) Tricyclics 249 (10.3%) 120 (6.1%) 110 (3.6%) 86 (3.5%) Mianserin 87 (3.6%) 37 (1.9%) 22 (0.7%) 8 (0.3%) Moclobemide 21 (0.9%) 40 (2.0%) 20 (0.6%) 9 (0.4%) SSRIs 18 (0.7%) 103 (5.2%) 354 (11.4%) 338 (13.7%) Venlafaxine — — 81 (2.6%) 61 (2.5%) Mirtazapine — — 51 (1.6%) 126 (5.1%) Lithium 11 (0.5%) 8 (0.4%) 24 (0.8%) 17 (0.7%) — = Drug not approved for use or not prescribed in year of survey. SSRI = selective serotonin reuptake inhibitor. * All percentages are proportion of total number of residents. † Clonazepam and other anticonvulsants (apart from diazepam) were not included as psychotropic drugs. ‡ Numbers do not add to totals as some patients were prescribed more than one drug and some little-used psychotropic drugs are not listed.

John Snowdon · Daniel Galanos · Divya Vaswani

To the Editor: I describe two episodes of transient recurrence of psychosis temporally related to ingestion of an “energy drink” in an obese (125 kg) 27-year-old New Zealand Maori man who had been diagnosed with schizophrenia 8 years earlier. The patient had found that risperidone 6 mg/day effectively relieved persecutory ideas and auditory hallucinations. He had stopped using cannabis and alcohol to excess, but continued to drink up to 10 cups of instant coffee throughout the day for a “lift”, apparently without insomnia or other complications. In July 2009, he consumed a 60 mL Demon Shot energy drink and enjoyed an hour-long “buzz”. Repeating the dose did not re-create the desired effect, and instead made him uneasy, irritable and paranoid; for the first time in many months, he had recurrent thoughts, lasting several hours, of people wanting to harm him. One week later, he drank three shots over 15 minutes. He again experienced a buzz and was observed to be emotionally labile — initially laughing and talkative, and later, restless, withdrawn and argumentative. He had a rapid pulse and insomnia. These symptoms subsided over the next day, and when he was back to his usual self after a further 2 days, he described having had paranoid ideas (“gangsters after me ... scared to leave the house”) over several hours after consuming the drinks. His family also associated these symptoms with the drinks, noting a striking similarity to his illness before commencing antipsychotic treatment. He has since avoided energy drinks and continued risperidone monotherapy, remaining stable for 15 months. Demon Shot is a concentrated energy drink, widely available in Australia and New Zealand. The product’s web page describes each “insanely intense” shot as containing 200 mg caffeine, plus taurine, guarana, and B vitamins (http://www.demonenergy.com.au/products/demon-shots). As a regular smoker, the patient does have increased caffeine metabolism, and his response to consuming large amounts of coffee suggests he is not particularly sensitive to caffeine. Nevertheless, he did exceed the maximum recommended dose (two shots per day) on the second occasion, consuming at least 600 mg of caffeine (4.8 mg/kg) virtually as a single dose. The additional presence of guarana extract (48 mg per shot in Australia; unspecified in New Zealand) is probably relevant, as guarana is a further source of caffeine and may have other stimulant properties. Caffeinated drinks are popular among patients being treated for schizophrenia,1 possibly due to partial reversal of the unpleasant effects of dopamine blockade.2 Although case reports3 and a later controlled study4 suggest that high doses of caffeine may exacerbate psychosis, this has only recently been described for energy drinks.5 This case provides naturalistic challenge–dechallenge–rechallenge evidence that some patients with treated schizophrenia may be vulnerable to exacerbation of their illness by such products.

David B Menkes

Effective dementia care depends on early and accurate diagnosis It is predicted that over the next 40 years there will be a fourfold increase in the prevalence of dementia in Australia, as well as considerably more people with milder forms of cognitive impairment.1 To date, despite extensive research, no effective treatment for established dementia is available. As a result, taskforce policymakers conclude that there is insufficient evidence at present to warrant routine screening for dementia syndromes.2,3 However, emerging evidence shows that early non-pharmacological intervention can improve cognitive outcomes for patients with milder forms of cognitive impairment and those at risk of cognitive decline.4 Early diagnosis also enables patients to plan, with their caregivers, for the future, and deal with matters such as enduring power of attorney authorisation, before they lose the capacity to do so. Over two-thirds of people who notice symptoms of cognitive decline consult a physician for evaluation.5 However, up to 90% of mild cases are missed at the initial primary care assessment.6,7 So how can we improve early detection of cognitive impairment, and what evidence base do we have for dementia screening in Australia? A diagnosis of dementia relies on a full mental status assessment, with comprehensive history taking and physical examination. Presently, detailed neuropsychological testing is the gold-standard tool for objectively evaluating the magnitude and pattern of cognitive decline. However, neuropsychological evaluation is costly, time-consuming and not generally available as only specialist psychologists can do it. Consequently, general practitioners and specialist physicians, who evaluate most patients presenting with cognitive complaints, administer brief screening instruments such as the mini-mental state examination (MMSE) to assess cognition. In Australia, the use of such instruments has been propagated by guidelines for prescribing acetylcholinesterase inhibitors. The MMSE has many documented and widely appreciated shortcomings. It lacks diagnostic specificity and is insensitive to patient variables such as extreme levels of education, premorbid ability and poor command of English.8 It has also been criticised for its unsystematic and atheoretical construction, and its poor ability to detect milder forms of cognitive impairment.8,9 The idea that any brief screening tool would have sufficient sensitivity and specificity to diagnose dementia is unrealistic. However, when used as an adjunct to a good clinical history, a more accurate instrument, particularly one that can be serially administered, would potentially increase the reliability of diagnosis. A recent review of screening instruments available for mild cognitive impairment concluded that there are more useful screening tools than the MMSE.10 Some are in use in Australia, including the Addenbrooke’s Cognitive Examination – Revised (ACE-R); the Alzheimer’s Disease Assessment Scale — cognitive subscale (ADAS-cog); and the Montreal Cognitive Assessment battery. In addition, there are other screening instruments specifically validated for use in Australia, such as the General Practitioner assessment of Cognition (GPCog) and Rowland Universal Dementia Assessment Scale (RUDAS). Recently, the ACE-R was validated for use in an Australian population.11 The ACE-R, which incorporates the MMSE, has been shown to have more diagnostic sophistication, with improved sensitivity and specificity values, than the MMSE alone. This is not to say that the ACE-R is without limitations. For instance, it cannot fully assess some aspects of cognitive function (eg, non-verbal skills). Furthermore, the ACE-R takes on average 16 minutes to administer and is therefore unlikely to see much uptake by busy GPs; however, it could be used by nurses working in general practices. As with all screening tools, clinicians using the ACE-R in the primary care setting need to be trained to correctly score and interpret patients’ ACE-R performances. Development of effective dementia treatments depends on earlier and more accurate identification of disease. Cognitive screening tests will continue to evolve, and may in time be replaced with screening for disease-related biomarkers. However, such diagnostic biomarkers have yet to be discovered. With the number of people with dementia growing each year, the lack of adequately validated diagnostic tools is a serious concern. Empirical investigations to further evaluate and validate screening instruments for cognitive impairment are necessary as we strive to develop effective treatments for all forms of this debilitating disorder.

Zoe Terpening BPsych(Hons), MSc, DClinNeuropsych · John R Hodges MD, FRCP, FMedSci · Nicholas J Cordato MB BS, PhD, FRACP

CorrectionIncorrect statement of risk: In “Factors associated with psychiatric morbidity and hazardous alcohol use in Australian doctors” in the 2 August 2010 issue of the Journal (Med J Aust 2010; 193: 161-166), there was an error in the first paragraph on page 163. The sentence regarding solo practitioners should read: “Solo practitioners had a lower risk of psychiatric morbidity than non-solo practitioners (OR, 0.78 [95% CI, 0.61–0.99]).” The html and pdf versions of this article were corrected on 10 November 2010.

Louise M Nash · Michele G Daly · Patrick J Kelly · Elizabeth H van Ekert · Garry Walter · Merrilyn Walton · Simon M Willcock · Chris C Tennant

Objective: To understand self-injury and its correlates in the Australian population.Design, participants and setting: Cross-sectional survey, using computer-assisted telephone interview, of a representative sample of 12 006 Australians from randomly selected households.Main outcome measures: Data on demographics, self-injury, psychiatric morbidity, substance use, suicidality, disclosure and help-seeking.Results: In the 4 weeks before the survey, 1.1% of the sample self-injured. For females, self-injury peaked in 15–24-year-olds; for males, it peaked in 10–19-year-olds. The youngest self-injurers were nine boys and three girls in the 10–14-year age group, and the oldest were one female and one male in the 75–84-year age group. Mean age of onset was 17 years, but the oldest age of onset was 44 years for males and 60 years for females. No statistically significant differences existed between those who did and did not self-injure on sex, socioeconomic status or Indigenous status. Most common self-injury method was cutting; most common motivation was to manage emotions. Frequency of self-injury during the 4-week period ranged from 1 to 50 instances (mean, 7). Self-injurers were significantly more psychologically distressed, and also more likely to use substances. Adults who self-injured were more likely to have received a psychiatric diagnosis. Self-injurers were more likely to have experienced recent suicidal ideation (OR, 11.56; 95% CI, 8.14–16.41), and have ever attempted suicide (OR, 8.51; 95% CI, 5.70–12.69). Most respondents told someone about their self-injury but fewer than half sought help.Conclusion: The prevalence of self-injury in Australia in the 4 weeks before the survey was substantial and self-injury may begin at older ages than previously reported. Self-injurers are more likely to have mental health problems and are at higher risk of suicidal thoughts and behaviour than non-self-injurers, and many self-injurers do not seek help.

Graham Martin MD, FRANZCP, DPM · Sarah V Swannell BPsych(Hons), GradCertBiostat · Philip L Hazell MB ChB, PhD, FRANZCP · James E Harrison MB BS, MPH, FAFPHM · Anne W Taylor BA, MPH, PhD

To the Editor: I cannot argue with the push by Hickie and McGorry for services for young people from 12 to 25 years of age who suffer from “depression”.1 But I question their sequencing of treatments model that pervades the beyondblue draft clinical practice guidelines about which they editorialise. Their model presupposes a unitary entity of “major depression” that varies in severity, with milder conditions being treated by psychotherapy and more severe conditions being treated with antidepressant medication. Consider the following case to show how the guidelines get it wrong. A 16-year-old girl presents with her first episode of moderately severe major depression. She is treated as per the guidelines for depression with a selective serotonin reuptake inhibitor (SSRI) and rapidly develops a severe psychotic mania. She is certified to a psychiatric facility and requires a prolonged admission. For the next 2 years she remains chronically hypomanic, refusing to try better treatment. Eventually, following a severe depressive episode, her treatment is reorganised and her condition stabilises. However, the trauma and psychosocial damage from the hospitalisation and prolonged period of illness are significant. In the guidelines, bipolar disorder — arguably the only “biological” kind of depression in this age group — is separated from the body of recommendations for managing depression. The possibility that this episode of depression may be part of an as-yet-undeclared bipolar disorder needs to be thoroughly integrated into the understanding and management of “depression”.2 Features that would suggest possible bipolar disorder include psychomotor retardation and cognitive impairment,3 psychosis, reverse neurovegetative features (hyper-somnia or hyperphagia),4 a few manic symptoms mixed with depression5 (racing thoughts, distractibility, flight of ideas, increased energy or psychomotor agitation), or the depression not making sense psychologically. Past episodes of depression, brief hypomania, anti-depressant-induced hypomania, or a family history of bipolar disorder also need to be documented. Doctors should then routinely discuss with patients and families the possibility that bipolar disorder could be diagnosed, and warn that the patient may experience a manic switch. If the likelihood is high, as part of a proper process of informed consent, the patient should be offered concurrent lithium or antipsychotic medication. The patient and family can be assured that expert clinical observation over time will clarify the diagnosis and what treatment is appropriate. This approach not only involves the patient and family in decision making, giving knowledge and choices, but, importantly, incorporates the reality of diagnostic uncertainty.

Norman P Zimmerman

In reply: Zimmerman correctly highlights the intrinsic limitations of applying the current “evidence base” for managing severe depression in young people. In part, our critique of the new guidelines1 stems from our shared concern about their real utility in clinical practice. As we have outlined elsewhere, we do not favour a simple “sequencing of treatments” model or recognise a clear separation between early phases of severe unipolar or bipolar depression.2 The real difficulty for clinicians is that young people presenting with severe depression are not only at high risk of immediate harm, but may also be on the path to a range of different psychiatric (and neurobiological) outcomes, including bipolar disorder, psychotic disorders and comorbid alcohol and substance misuse.2,3 Unfortunately, there are no clear clinical, neuropsychological or biomedical predictors of the relative risks of developing these adverse outcomes.2,3 Consequently, we have recommended the development of a broader clinical trials network that recognises this complexity and seeks to develop a more relevant evidence base in the future.4 For now, we need to continue to develop clinical service initiatives that not only engage young people but can provide the longitudinal and more specialised care that may be required for those who develop more complex disorders.5

Ian B Hickie · Patrick D McGorry

Objective: To evaluate the impact of psychiatric inpatient bed closures, accompanied by a training program aimed at enhancing team effectiveness and incorporating data-driven practices, in a mental health service.Design and setting: Retrospective comparison of the changes in services within three consecutive financial years: baseline period — before bed reduction (2006–07); observation period — after bed reduction (2007–08); and intervention period — second year after bed reduction (2008–09). The study was conducted at Cramond Clinic, Queen Elizabeth Hospital, Adelaide.Main outcome measures: Length of stay, 28-day readmission rates, discharges, bed occupancy rates, emergency department (ED) presentations, ED waiting time, seclusions, locality of treatment, and follow-up in the community within 7 days.Results: Reduced bed numbers were associated with reduced length of stay, fewer referrals from the community and subsequently shorter waiting times in the ED, without significant change in readmission rates. A higher proportion of patients was treated in the local catchment area, with improved community follow-up and a significant reduction in inpatient seclusions.Conclusion: Our findings should reassure clinicians concerned about psychiatric bed numbers that service redesign with planned bed reductions will not necessarily affect clinical care, provided data literacy and team training programs are in place to ensure smooth transition of patients across ED, inpatient and community services.

Tarun J Bastiampillai MB BS, BMedSc, FRANZCP · Niranjan P Bidargaddi BE(CompSc), PhD · Rohan S Dhillon MB BS, FRANZCP, MClinSc · Geoffrey D Schrader FRANZCP, PhD · Jörg E Strobel MD, FRANZCP · Philip J Galley RMN, DipCPC, BA(Hons)

To the Editor: Pridmore1 describes a case in which a man’s recent actions suggested suicidal intent. The man told police he had no ongoing suicidal plans and they took his words at face value. He subsequently killed himself. The High Court exonerated the police of any responsibility, a decision that seemed based on two premises: that suicide does not presuppose mental disorder; and that “There is no general common law duty of care to rescue a person from harm, including self-harm”.2 There is sufficient grey in both those inter-related premises to make a black-and-white judgment suspect. I share Pridmore’s position that suicide does not always equal mental disorder, although one wonders whether situational crises in individuals with subtle vulnerabilities could be subsumed under such a label. More important is the question of individual autonomy. The reason we have no common law requiring us to “rescue” another adult is because we set such a high value on autonomy. Although we assume a person’s competence, our curiosity about it should be aroused when people behave in unexpected ways. When the behaviour is strikingly different, and has potential for serious harm, are we not obliged to intervene or procure assessment? This is, I would have thought, a moral rather than legal or medical concern. This is what we would do for a child wandering on the road or a demented person lost at night. We might be free of legal or medical censure for ignoring them, but we would be embarrassed to publicly admit our failure to act if we might have done something useful at the time. Making serious preparation to kill yourself is strikingly different behaviour, and should raise questions about both your competence and autonomy. Perhaps not 100% but surely more than 50% of such people have a disorder. A person preparing to suicide is “more likely than not” mentally ill, and that is how the “common person” would surely see it: “guilty”, as it were, till proven innocent. Expertise is called for to make that final determination. The police certainly do not have the expertise. Why, then, would they not seek it? Furthermore, if the “rational, cooperative and responsible” man in this case had indicated his plans to “rationally” commit suicide to escape an intolerable predicament, it is hard to believe the police would have walked away, even though he may have been competent to make such a decision!

Paul T Dignam

To the Editor: We read with interest the recent meta-analysis of rates and methods of suicide in Australia by Large and Nielssen.1 Previous research has shown a marked increase in hanging suicides in women in South Australia over the 15-year period 1986 to 2000,2 which concurs with the findings of Large and Nielssen at a national level between 1988 and 2007.1 One of the features of this increase in hanging suicides, which was not specifically addressed in their excellent overview, relates to trends in specific age groups such as the young. A previous analysis of suicides in individuals aged 16 years and under and for whom autopsies were performed at the Forensic Science Centre (now Forensic Science South Australia; FSSA), in Adelaide,3 included a total of 19 cases of suicide for the 5 years 1985 to 1989, of which seven deaths (37%) were from hanging. The age range of the hanging victims was 14–16 years (mean age, 15 years), with a male to female ratio of 6:1. This compares with a total of 10 suicides among young people, recorded in FSSA files for the 5 years 2005 to 2009, of which nine (90%) were by hanging. The age range of the hanging victims in this group was 10–16 years (mean age, 14.7 years), with a male to female ratio of 4:5. The difference between these two periods was statistically significant (P < 0.005).3 Thus, although suicide in those aged 16 years and under remains an uncommon event,3 developments in deliberate self-harm among the general population may also be reflected in the young. While there was a fall in the total number of young suicide victims, from 19 to 10, between the two periods in the SA study, this has not been matched by a decline in hanging suicides (ie, a significantly greater percentage of suicides in the young in SA now involve self-suspension).3 This finding may be of use to those studying specific issues and trends in youth suicide.

Roger W Byard · Amy Austin · Corinna van den Heuvel

The casket was not carried out, instead was wheeled. Appalled family walked either side, his mother riding in a chair behind, reaching out a black-clad arm to touch then hold the lid somewhat obscured by flowers. He was forty-eight. Voices resistant to the medications, having torn his soul with strident assertions, instructed him how to plait his hair, to tie the knot, to place the chair and kick it out. This is the best that we could do — we are short of resources for mental health. We have to fund forces in Afghanistan, invest in new buildings, do countable things. He was an artist at times pencilling the Blue Mountains, arcades in The Rocks. After years his wife left him, a frowning alien cut off from relatives who found him, cut him down.

Stephen Leeder

Cancer care must incorporate the psychosocial and biological The clinical oncologists of all stripes have, for too long, overlooked or ignored the psychological factors that may, for all we know at present, play a surprisingly large role in individual susceptibility to neoplasia. They are certainly influential in affecting the course of treatment, the adaptation to the illness, and hence, in some ways, not all of which are yet understood, affect the outcome of treatment. Lewis Thomas in the foreword to the Handbook of Psychooncology, 19891 The publication of the Handbook of psychooncology,1 later to grow into the substantial textbook Psycho-oncology,2 heralded the beginning of the field of psychooncology. Psychological factors had long been linked with the cause or progress of much human illness, and yet were being increasingly ignored because of a lack of substantial evidence and a strengthening of the biological understanding of disease. The work represented by the publication of these volumes identified the beginning of both a clinical and research interest that continues strongly to this day. Cancer is the first field of medicine where psychosocial factors have been taken seriously. This was partly because of the potency of cytotoxic drugs and the severity of adverse effects. This led to a need to consider “quality of life”, and to balance this with gains in longevity of life. Quality of life is a subjective matter that requires consideration of complex psychosocial and relational matters and values. These cannot be measured by blood tests. In addition, cancer, more than any other disease, confronts us all with serious existential issues. It challenges the sense of control we might think we have over our lives, and raises the possibility of the purposelessness and futility of life, as well as raising questions about what is a good life and a good death. The field of psychooncology has contributed much over the years. We have seen serious attention given to communicating “bad news” to patients and to “truth telling”, maximising patients’ involvement in care decisions and maintaining dignity. Various behavioural and psychological interventions have been shown to be effective in relieving patients’ anxiety and depression. Attention has been given to the stress that carers and loved ones experience through the cancer journey, and how strained the support networks can be at times; at other times and for other people, the cancer journey can be a “growth” experience.3 The articles in this Medical Journal of Australia supplement showcase the quality of work currently being done in this area. They range from the use of a large epidemiological survey to tease out the connections between cancer and depression,4 to descriptions of systemic interventions of screening and psychosocial care.5 There is evidence for the effectiveness of psychosocial interventions in relieving distress and assisting in psychosocial adjustment for people in the experience of cancer, although much work remains to be done. Current levels of evidence have been well summarised in published National Health and Medical Research Council (NHMRC) guidelines.6 However, these interventions are not routinely offered by cancer services to patients and their families. So, despite the development of an evidence base over the past few decades, and the acknowledged good things happening in the clinical domain in the area of communication skills for health professionals,7 clinical practice lags behind evidence and standards of best practice. To correct this, we need champions in the field talking about the issue, consumers and carers participating in the research and sharing their experiences, and leading practice-policymakers and health providers with the moral courage to fully implement “evidence-based” and humane care beyond the trial phase. The importance of this is not diminishing as medical science takes us into new areas (such as genetic screening, which is producing a cohort of people who, while well, live with the anxiety of developing cancer at any time in their life), which throw up ever- new ethical and clinical challenges. beyondblue and Cancer Council Australia are committed to working together towards seeing the development of an integrated approach to cancer care incorporating the psychosocial and biological; and beyondblue will continue to encourage and support research that advances knowledge and improved practice in the area by investing in applied research and by partnering with Cancer Australia in the NHMRC’s Priority-driven Collaborative Cancer Research Scheme.

David M Clarke PhD, FRACGP, FRANZCP

Objectives: To examine the prevalence and predictors of depression and anxiety in palliative care patients with cancer in Western Australia and New South Wales.Design, setting and participants: A descriptive study of 266 consecutive patients at a range of inpatient and outpatient settings including home care, hospices, and private and tertiary care hospitals in WA and NSW from 1 March to 30 June 2002.Main outcome measures: Self-reported anxiety and depression using the Hospital Anxiety and Depression Scale (HADS) at a cut-off score of ≥ 8 on each subscale (depression and anxiety) for possible cases, and of ≥ 11 for probable cases; a cut-off score of ≥ 19 was used for probable combined depression and anxiety.Results: Patients included 200 in WA and 66 in NSW. For the whole sample, 45.8% of patients were possibly depressed and 22.7% probably depressed; 36.9% were possibly anxious and 19.8% probably anxious. About 25% of patients had probable combined depression and anxiety. Logistic regression analyses indicated that past anxiety in the family predicted probable depression, while age, marital status and past depression predicted probable anxiety. Age and past depression predicted probable combined depression and anxiety.Conclusions: These findings underscore the need for routine screening for anxiety and depression in palliative care settings, including questions about past personal and family history of anxiety and depression, and the need for a range of interventions and support services.

Moira O’Connor BA(Hons), MSc, PhD · Kate White RN, MN, PhD · Linda J Kristjanson BN, MN, PhD · Kerry Cousins RN, BN · Lesley Wilkes PhD, RN, CM

Objective: To assess symptoms of depression and anxiety in patients with head and neck cancers (HNCs) before and after radiotherapy.Design, participants and setting: Prospective observational study of 102 outpatients with HNCs at a tertiary cancer centre in Melbourne between 1 May 2008 and 30 May 2009. Eligibility criteria were a first-time diagnosis of HNC, age over 17 years, and agreement to undergo cancer treatment involving radiotherapy with curative intent. Data were collected before commencement of radiotherapy and again 3 weeks after completing treatment.Main outcome measures: Symptoms of depression and anxiety as assessed by the Hospital Anxiety and Depression Scale (HADS); physical and psychosocial aspects of quality of life as assessed by the Functional Assessment of Cancer Therapy–Head and Neck (FACT-H&N).Results: Seventy-five participants completed pretreatment and posttreatment questionnaires. Mean depression scores increased significantly from before to after treatment, while anxiety scores decreased significantly over the same period. The prevalence of mild to severe depression was 15% before treatment and 31% after treatment. The prevalence of mild to severe symptoms of anxiety was 30% before treatment, reducing to 17% after treatment. Posttreatment depression was predicted by pretreatment depression and receiving chemotherapy. Posttreatment anxiety was predicted by pretreatment anxiety and male sex.Conclusions: These findings suggest that rates of depression in patients with HNCs increase after cancer treatment, with a third of patients experiencing clinically significant symptoms of depression after radiotherapy.

Kate A Neilson BBSc(Hons), DPsych(Clinical) · Annabel C Pollard RN, GradDipAppPsych. MPsych(Clinical) · Ann M Boonzaier BA(Hons), MA(Psychology), DPsych(Clinical) · June Corry MD, FRACP, FRANZCR · David J Castle MD, MRCPsych, FRANZCP · Karen R Mead BAHons(Psychology), MPsych(Clinical) · Marcelle C L Gray BA(Psychology), PGradDip(Psychology) · David I Smith BBSc(Hons), MPsych, PhD · Tom Trauer PhD, ABPsS, MAPsS · Jeremy W Couper MD, MMed(Psych), FRANZCP

Objectives: To assess the prevalence and predictors of depression and anxiety in women with ovarian cancer and their caregivers, to compare levels of depression and anxiety with community norms, and to explore the relationship between patients and their nominated caregivers.Design, setting and participants: Prospective cohort study of 798 women with invasive ovarian cancer recruited between 1 January 2002 and 30 June 2006 through the nationwide Australian Ovarian Cancer Study, and 373 of their caregivers.Main outcome measures: Depression and anxiety as assessed with the Hospital Anxiety and Depression Scale, and the role of demographic variables, disease and treatment variables, psychosocial variables, and use of mental health and support services as potential predictors.Results: Rates of anxiety and depression among patients were significantly lower than in previous reports, although clinical depression rates (5.9%) were significantly higher than community norms (3.0%; χ2 = 24.0; P < 0.001). Caregivers also reported higher levels of depression (χ2 = 21.1; P < 0.001) and anxiety (χ2 = 17.6; P < 0.001) compared with norms. There was no difference within patient–caregiver pairs for depression (P = 0.1), while caregivers reported significantly higher anxiety than patients (P < 0.01). In patients, higher symptom burden, lower optimism and current specialist mental health treatment all significantly predicted both depression and anxiety, while lower social support was a significant predictor of patient anxiety only. In caregivers, lower social support and lower optimism were significant predictors of depression and anxiety. Patients being treated for mental health was also a predictor of their caregiver’s depression.Conclusions: While depression is significantly more common in women with ovarian cancer than in the general population, it is caregivers of such patients who report much higher levels of both subclinical and clinical depression and anxiety.

, the Australian Ovarian Cancer Study Group and the Australian Ovarian Cancer Study Group Quality of Life Study Investigators

Objective: To assess psychosocial distress in patients with early (localised) and advanced (metastatic) prostate cancer (PCA) at diagnosis (Time 1) and 12 months later (Time 2), and identify psychosocial factors predictive of later distress.Design, participants and setting: Observational, prospective study of 367 men with early (211) or advanced (156) PCA recruited as consecutive attendees at clinics at seven public hospitals and practices in metropolitan Melbourne between 1 April 2001 and 30 December 2005. Both groups completed questionnaires at Time 1 and Time 2.Main outcome measures: Health-related quality of life as assessed by the Short Form 36-item Health Survey; psychological distress, including depression and anxiety as assessed by the Brief Symptom Inventory; and coping patterns as assessed by the Mini-Mental Adjustment to Cancer scale.Results: Over the 12 months, both the early and advanced PCA group showed reduced vitality and increased depression and anxiety; this effect was greater in the advanced PCA group. Mental health, social functioning and role-emotional functioning also deteriorated in the advanced group. Predictors of depression at Time 2 for the early PCA group were depression, vitality and a fatalistic coping pattern at Time 1; anxiety at Time 2 was predicted by anxiety and vitality at Time 1. In the advanced PCA group, depression at Time 2 was predicted by depression and mental health at Time 1; anxiety at Time 2 was predicted by anxiety, mental health, cognitive avoidance and lower anxious preoccupation at Time 1.Conclusions: Men with early PCA experience decreasing vitality and increasing psychological distress over the 12 months following diagnosis; this trend is accelerated after diagnosis with advanced PCA. A fatalistic coping pattern at diagnosis of early PCA predicts later depression while cognitive avoidance and lower anxious preoccupation at diagnosis of advanced PCA predict later anxiety.

Jeremy W Couper MD · Anthony W Love PhD · Gillian M Duchesne MD · Sidney Bloch PhD · Michelle Macvean PhD · Judy V Dunai PhD · Marita Scealy DPsych · Anthony Costello MD · David W Kissane MD